An audit of the appointment booking system and patient waiting time in an ultrasound unit in Nigeria: A need to eliminate congestion in our public hospitals.

BACKGROUND: Congestion of patient waiting areas at commencement of work is the usual scenario in Nigeria's public hospitals. This strains the personnel and facilities. Patients are dissatisfied and lose faith in the system. This study aims to audit the booking system, patient waiting time, and causes of congestion in an ultrasound unit.
MATERIALS AND METHODS: This is a prospective, descriptive study involving 350 patients referred from general outpatient and specialist clinics to the ultrasound unit, twice weekly for 6 weeks. Patients were grouped into two: those with scheduled appointments and the unbooked. The time of scheduled appointment and arrival in the unit and the time of commencement and conclusion of the examination were recorded.
RESULTS: Three hundred and eighteen patients had scheduled appointments, while 32 were unbooked. Half of the later were emergencies and the other half were walk-ins. There was no consistency in number of slots and block size. Large blocks of over 20 patients were observed on 33.3% of the days and 51.26% of the patients were given 8:00 am appointments. The average patient waiting time is 132.11 minutes but range from 62 to 220 minutes daily. The radiologists resumed work between 8:17 and 9:29 am each scan day. The average waiting time is shorter for patients who arrived after 11:00 am.
CONCLUSION: Ineffective booking of appointments and Sonologist's tardiness are major predisposition to congestion. Appointments in small blocks at 30 minutes intervals will eliminate congestion, reduce patient waiting time, and improve satisfaction. Point-of-care ultrasound should be introduced in outpatient clinics.

Introduction

Congested patient waiting areas are common sight at the commencement of work in primary care and specialist clinics, and ultrasound units of most public hospitals in Nigeria. This negatively impacts on the patient waiting time (PWT) i.e length of time between arrival in the clinic/unit to when being attended to. Patient's satisfaction is observed to be strongly influenced by the PWT.[1] Patient-centered radiology is a relatively new concept in service delivery[2] to improve satisfaction. This study aims to audit the appointment booking system and other causes of congestion in an ultrasound unit and their effect on PWT.

Materials and Methods

This is a cross-sectional descriptive study in a secondary healthcare facility in Calabar, Cross river State, Nigeria. The hospital has an outpatient department run by primary care physicians and other specialized departments. The study involves 350 patients referred mainly by the primary care physicians. The patients are scanned in the ultrasound unit of the radiology department during regular work hours on the two scan days each week (Tuesday and Thursday), for a 6 weeks study period. The average waiting time is calculated only for patients with scheduled appointments, while the average service time is calculated using data from all patients. The patient waiting area is just in front of the ultrasound room. Patients are attended to on first-come, first-served basis, except emergencies. Patients not well prepared for the examination by prior adequate ingestion of water to fill the urinary bladder for pelvic scan and adequate duration of fast for abdominal examination also lose their turns. The radiologists and patients were not informed of the study, so as not to influence the outcome. The data were obtained from the request forms by trained medical assistants in the waiting area who extract the age, gender, time of appointment when applicable, and type of examination. Patients are sorted into two groups depending on prior scheduled appointment or if unbooked. The assistants also record three timelines of the patients: time of arrival in the unit, time called for the examination, and the time it ended. The data were analyzed using simple statistical methods. The results are presented in tables and figures.

Result

Only one ultrasound machine was operational on each scan day. There are two consultant radiologists but only one conducts the examinations each scan day. Figure 1 shows the nature of their visit to the unit. A total of 318 (90.86%) were scheduled appointments with an average of 26.5 patients per day. Figure 2 shows the gender distribution of the patients. Table 1 illustrates the age distribution of the patients. It ranges from 1 to 95 years with an average of 32.40 years. Table 2 shows the detailed appointment schedule of the patients with time slots, while Table 3 summarizes this and includes the rates of punctuality. Table 4 shows the distribution of patients according to the time spent waiting to be scanned. Table 5 gives an overview of the work flow, appointment compliance rate, and the average PWT. The overall average PWT is 132.11 minutes, with a daily range of 62.68 to 220.58 minutes. Work in the ultrasound unit commenced between 8:17 am and 9:29 am, and ends before the close of work by 4:00 pm on all the scan days. Table 6 presents the PWT in relation to when they arrived in the unit. The ultrasound examinations requested for and their average service time are shown in Table 7.

Figure 1

Nature of visit to the ultrasound unit

Figure 2

Gender distribution of patients

Table 1

Age distribution of all patients; booked and unbooked (Original)

Age group (years)	Number of patients (n)	Percentage (%)
1 - 10	5	1.43
11 - 20	23	6.57
21 - 30	155	44.29
31 - 40	118	33.71
41 - 50	24	6.86
51 - 60	8	2.29
61 - 70	13	3.71
71 - 80	3	0.86
81 - 90	0	0
91 - 100	1	0.29
Total	350	100

Table 2

Appointment schedule of patients (Original)

Week	Day	Time slot (am)	Number of patients (n)
1	Tuesday	7:00	1
	Thursday	7:15	1
		7:20	1
		7:30	14
		8:00	15
		7:30	13
		8:00	9
		8:30	1
2	Tuesday	7:30	15
	Thursday	8:00	10
		7:30	8
		8:00	8
3	Tuesday	8:00	16
	Thursday	8:30	7
		9:00	5
		9:30	1
		7:30	2
		8:00	21
		8:30	18
4	Tuesday	7:30	1
	Thursday	8:00	17
		8:30	2
		8:00	9
		8:30	8
		9:30	2
5	Tuesday	7:30	1
	Thursday	8:00	30
		8:30	7
		9:00	2
		7:30	4
		8:00	10
		8:30	10
		9:00	4
6	Tuesday	7:30	3
	Thursday	8:00	10
		8:30	8
		9:00	5
		9:30	3
		8:00	9
		8:30	6
		9:00	5
		9:30	6
			Total=318

Table 3

Summary of the scheduled time of appointment of patients (Original)

S/N	Appointment time (am)	Total number of patients (n)	Percentage (%)	Number of early patients (n)	Number of late patients (n)
1	7:00	2	0.63	1	1
2	7:15	1	0.32		1
3	7:20	1	0.32		1
4	7:30	61	19.18	7	54
5	8:00	163	51.26	8	155
6	8:30	57	17.92	10	47
7	9:00	21	6.6		21
8	9:30	12	3.77		12
	Total	318	100	26	292

Table 4

Distribution of patient waiting time (Original)

Waiting time (minutes)	Number of patients (n)	Percentage (%)
0 - 15	8	2.52
16 - 30	12	3.77
31 - 45	19	5.98
46 - 60	30	9.43
61 - 90	46	14.47
91 - 120	51	16.03
121 - 180	72	22.64
181 - 240	43	13.52
241 - 300	22	6.92
301 - 360	15	4.72
Total	318	100

Table 5

Work flow, compliance with appointment, and the average patient waiting time in the Ultrasound unit (Original)

Week/Day	Time work starts	Number of patients waiting at start of work (n)	Total number of patients seen (n)	Number of no-show (n)	Number of unbooked patients (n)	Time of conclusion of last scan	Range of patient waiting time (minutes)	Average patient waiting time (minutes)	Percentage Utilization of equipment (%)
1. Tuesday Thursday	09:12	28	32	5	0	13:15	01 - 265	163.06	50.63
	08:31	12	24	1	2	12:27	27 - 248	130.68	49.17
2. Tuesday Thursday	08:44	19	29	8	4	12:44	64 - 234	160	50.00
	09:09	22	25	9	9	14:25	45 - 167	101.31	65.83
3. Tuesday Thursday	08:52	3	31	5	2	14:17	0 - 146	73.93	67.71
	08:17	9	32	2	1	12:00	03 - 123	66.58	46.46
4. Tuesday Thursday	09:29	20	22	8	2	13:31	52 - 253	165.35	50.42
	09:21	4	27	8	8	15:40	03 - 307	213.74	79.96
5. Tuesday	08:53	29	42	7	2	15:42	38 - 355	220.58	85.21
Thursday	08:27	7	28	3	0	11:10	41-102	62.68	33.96
6. Tuesday	08:34	16	31	9	1	12:25	14 - 214	99.77	48.13
Thursday	08:56	13	27	6	1	13:48	47 - 181	127.6	60.83
Total		182	350	71	32

Table 6

Average patient waiting time based on time of arrival (Original)

Time	Patients (n)	Percentage (%)	Range of patient waiting time (minutes)	Average patient waiting time (minutes)
7:01 - 8:00	25	7.86	21 - 265	126.4
8:01 - 9:00	176	55.35	3 - 315	132.66
9:01 - 10:00	73	22.96	0 - 355	144.21
10:01 - 11:00	26	8.18	25 - 306	135.5
11:01 - 12:00	14	4.40	1 - 262	83.14
12:01 - 13:00	1	0.31	195	195
13:01 - 14:00	3	0.94	12 - 74	45.33
	318	100

Table 7

Average time of the ultrasound services (Original)

S/N	Type of ultrasound service	Number of exams (n)	Percentage (%)	Average service time (minutes)
1	Abdominal	14	4	8.28
2	Abdominopelvic	90	25.71	7.74
3	Breast	10	2.86	7.6
4	Neck	3	0.86	12.33
5	Obstetrics	168	48	6.82
6	Ocular	2	0.57	4.5
7	Pelvic	54	15.43	6.18
8	Scrotal	6	1.71	15
9	Soft tissue	3	0.86	10
	Total	350	100

Discussion

When a lot of clients arrive in an ultrasound unit about the same time, it causes congestion. Patients caught up in this clog are referred with a myriad of requests, requiring specific preparations and with varied service time. Similarly, primary care patients and their needs are not homogenous. Patients are dissatisfied when they have to wait a long time before being attended to. Their level of satisfaction ultimately affects the rating of the quality of care offered in the unit or department.[3]

Besides trying to satisfy patients, managers of ultrasound units need to look for ways to eliminate or reduce to the barest minimum, the idle time (period of nonutilization during the regular working hours) of the radiologists or ultrasound machine. An effective coordination of these two major responsibilities with the use of an appointment booking system is lacking in most public hospitals in Nigeria and some other lower-middle and low-income countries. Patient dissatisfaction due to a long wait has been reported to be a reason why some of them will not return to the unit/clinic for care in future.[45] A lot of them resort to expensive, small private hospitals run by one radiologist or physician who may not have the specific expertise being sort after by the patients. The lengthy waiting time is not unique to one unit or department in the hospital, but occurs in virtually all, including ophthalmology and radiology.[36] The PWT in other departments like the outpatient clinics run by primary care physicians, which have been well researched, cannot be compared with or used as a performance metric in the ultrasound unit because of the peculiar protocols/preparation (adequate ingestion of water to distend the urinary bladder for transabdominal pelvic scan and at least a 6 hours of fast for proper assessment of the gallbladder, stomach, and pancreas) required before clients are scanned. This necessitated this baseline study, specifically in the ultrasound unit to obtain data for the development of an effective booking system that guarantees patient satisfaction and optimal unit performance.

Our study revealed that the major underlining cause of congestion in the waiting area is the type of appointment scheduling adopted in the unit. The time of schedule, block size, and time slots are not consistent. The slots vary from 2 to 5, usually at 30 minutes interval. Most of the patients were given 8:00 am appointment (51.26%) and majority of the remaining were slated for 7:30 am (19.18%) and 8:30 am (17.92%). A suggestion made following a study in Australia, where one of the operational efficiency strategies to prevent long waiting time and congestion is to avoid giving appointment to large blocks of patients.[7] This is however what is practiced in the unit we studied, where as much as 29 patients were given 8:00 am appointment on one of the days. An effective appointment system is meant to make patients have short unit or departmental waiting time while reducing or eliminating the idle time of the physician, equipment, or room.[89] Lots of innovations in appointment scheduling in other fields have been adopted and modified in medicine to reduce the number of clients present in a healthcare facility or department at a specific time and improve patient flow. These were achieved through computer engineering software programs which has also been utilized in ultrasound suites.[10] These appointment scheduling systems have been put to use in medicine in the western world and parts of Asia with tremendous gains in reducing PWT and improvement in patient satisfaction.[11112] An online-based scheduling system was developed in Nigeria for national health insurance scheme (NHIS) patients in 2014,[13] but this was not used in this unit being studied and in most of the hospitals in the country. This system allowed patients to book and manage their appointment online.

This index study also revealed lack of compliance with appointments by the patients. Firstly, a total of 71 (18.25%) patients did not show up for their appointment (no-show) and this gives an approximate average of six patients each day. Secondly, only 26 (8.18%) arrived on time for their scheduled appointment, while 292 (91.82%) came late. This relatively high rate of “no-show” and lateness for appointment is largely due to lack of input from the patients when scheduling it and probably because they know scanning commence late. Patients should be allowed to choose a convenient day and time for their examinations, and adjust it accordingly themselves, when the need arise, as long as it is within the time frame for the submission of the report to the referring physician. Patient self-scheduling is one of the new intervention introduced to allow patient manage their booking, which will reduce the rate of no-show and cancellations. It was projected that by 2019, 66.0% of United States hospitals will offer patients self-scheduling service.[14]

The other cause of congestion in this study is the lateness of the radiologists due to other duties outside the ultrasound unit. Promptness at work is one of the key indicators of quality of service.[12] The earliest and latest time work commenced in the ultrasound unit in our study is 8:17 am and 9:29 am respectively. This resulted in patients arriving long before the radiologists. In 66.67% of the scan days, over 10 patients arrived in the unit before scanning started and in 33.3% of the days, over 20 patients were already seated in the waiting area before the first patient was called in to be examined.

The major effect of the congestion caused by the appointment scheduling system and tardiness of the radiologist in this study is a long PWT. The waiting time for an examination is an important patient centered performance index, to measure service satisfaction or dissatisfaction.[215] A PWT of 60 minutes or less was observed to be one of the factors associated with patient satisfaction.[16] Sadly, 78.3% of the patients in our study waited for more than 60 minutes before they were called in to be scanned. This is higher than the findings in a study carried out in the outpatient department of a tertiary hospital in northern Nigeria where 69% spent more than 60 minutes in the waiting room.[17] Although, one of the patients did not wait before being called in, some waited for more than 300 minutes, with the longest wait being 355 minutes. The overall average PWT is 132.11 minutes but this range from 62.68 to 220.58 minutes daily. Though a significant number of emergencies requiring urgent scans can adversely affect the planned flow of scheduled patients, this wasn’t the case in the index study because they were only 4.57% (N = 16) of the total number of patients, with an approximate average of three patients each day. Our study also show that the average PWT increased steadily with the arrival time, from 7:00 am to 10:00 am with an equally steady decline thereafter, to the shortest time which was observed for those that arrived after 11:00 am. This shows that patient who come late have quicker access to service.

Though Osundina and Opeke[18] recommended employing more primary care doctors in general outpatient department to reduce the PWT, this will not be the most appropriate intervention in this ultrasound unit because the equipment/staff utilization rate is not optimal and all the patients were seen before the close of work. What is needed to eliminate congestion and reduce waiting at no extra cost, is the development of an appropriate scheduling system that will guarantee an efficient allocation of patients into blocks and time slots at intervals that enable quick access to scan room. The development of this system will be influenced by the findings in this baseline survey: the actual time work commences in the unit so patients don’t arrive before the radiologist, the average number of emergencies each scan day and the average service time for the different types of examinations to help determine an appropriate number of patients to be put in each block with workable time slots and intervals. Patients will also be allowed to choose a convenient date and time for their examination to prevent patient's lateness and no-show.

In busier ultrasound units, where the volume of referrals is much, further intervention is required. The ultrasound scan has to be decentralized. Instead of performing the ultrasound scans in the radiology department on a scheduled appointment usually at a future date, a quicker access to service can be achieved with the introduction of point-of-care ultrasound (POCUS), which will be carried out by primary care physicians who have been properly trained in basic or specific regional examinations. In a review article published in 2012, 15 out of the 35 articles revealed that POCUS was already practiced by primary care physicians.[19] In order to formalize the training and widen it practice, a pilot study for family medicine residents was carried out in 2013. Training sessions on POCUS were organized for them using hand-carried ultrasound machines.[20]

Conclusion

Ineffective appointment booking system is the primary cause of congestion in the ultrasound unit. This is compounded by the radiologist's tardiness. Lack of compliance with appointments and a long PWT are the resultant effect. Hospitals need to develop appointment booking systems, which schedule patients in appropriate block size that are properly spaced out and also allow them choose the most convenient time slot in order to keep to it. This will be based on the knowledge of key variables. Furthermore, introduction of POCUS carried out by primary care physicians in outpatient departments will shorten patient access to the service and reduce referrals to the ultrasound units of radiology departments.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.